Bladder Cancer
In the United States, bladder cancer is the fourth most common type of cancer in men and the ninth most common cancer in women. More than 51,000 men and 17,000 women are diagnosed with bladder cancer each year, with around 14,000 deaths in total. One reason for its higher incidence in men is that the androgen receptor, which is much more active in men than in women, plays a major part in the development of the cancer.
Incidence of bladder cancer increases with age. People over the age of 70 develop the disease 2 to 3 times more often than those aged 55-69 and 15 to 20 times more often than those aged 30-54. Bladder cancer is 2 to 3 times more common in men. Smoking is a major contributory factor, accounting for up to 65 percent of cases in men and 30 percent of cases in women in developed countries.
It has been estimated that approximately US$2 billion is spent in the United States on treating bladder cancer. The NCI's investment in bladder cancer research has increased from US$19.1 million in 2000 to an estimated US$34.8 million in 2005.
Bladder Cancer Diagnosis
Most patients when first diagnosed with bladder cancer have their cancer confined to the bladder (74%). In 19% of the cases, the cancer has spread to nearby tissues outside the bladder and in 3% it has spread to distant sites.
Bladder cancer can be diagnosed using cystoscopy, biopsy, urine cytology and imaging tests such as an intravenous pyelogram (IVP), computed tomography (CT) scan, magnetic resonance imaging (MRI) scan or ultrasound.
Bladder Cancer Staging
Bladder cancer is staged using the American Joint Committee on Cancer (AJCC) TNM system—stage I-IV.
Bladder Cancer Treatment
The main types of treatment for bladder cancer are surgery, radiation therapy, immunotherapy and chemotherapy. Surgery, alone or combined with other treatments, is used in more than 90% of cases. For early stage or superficial bladder cancer, a transurethral resection (TUR) is most common. About 70-80% of patients have superficial cancer when first diagnosed. When the bladder cancer is invasive, a cystectomy is sometimes necessary. An alternative approach for locally advanced bladder cancer can be a TUR along with radiation therapy and chemotherapy.
Bacillus Calmette-Guerin (BCG) can be used as immunotherapy for treating low-stage bladder cancer.
Neoadjuvant or adjuvant chemotherapy can be used in the treatment of bladder cancer. Mitomycin and thiotepa are the drugs most often used for intravesical chemotherapy. Systemic chemotherapy combinations used to treat bladder cancer include M-VAC (methotrexate, vinblastine, doxorubicin and cisplatin), MCV (methotrexate, cisplatin and vinblastine) and GemCIS (gemcitabine and cisplatin).
External beam radiation therapy or local or interstitial radiation therapy can be combined with chemotherapy after surgery.
Bladder Cancer Survival by Stage:
StageRelative 5-year Survival Rate095%I85%II55%III38%IV16%Breast Cancer
Globally, breast cancer is both the most common cancer (10% of all cancer cases) and the leading cause of cancer death (6% of cancer deaths) in women. Global incidence of breast cancer is over 1 million cases per year, with about 400,000 deaths. Women in North America have the highest rate of breast cancer in the world (over 200,000 new cases per year, with about 40,000 deaths). The chance of developing invasive breast cancer at some time in a woman's life is about 1 in 8. Breast cancer incidence increases with age, rising sharply after age 40. In the USA, about 77% of invasive breast cancers occur in women over age 50. It has been estimated that approximately US$8.1 billion is spent in the USA each year on treating breast cancer.
Breast Cancer Diagnosis
Early diagnosis improves the likelihood that treatment will be successful. Screening methods such as mammograms, clinical breast examinations and breast self-examinations are useful in detecting breast cancer. Current diagnostic methods include breast ultrasound, ductogram, full-field digital mammography (FFDM), scintimammography and MRI. A biopsy (fine needle aspiration biopsy, core biopsy or surgical biopsy) is then performed to confirm the presence of breast cancer. Imaging tests such as a chest x-ray, bone scan, CT, MRI and PET are used to detect if the breast cancer has spread.
Breast Cancer Staging
Breast cancer is staged using the American Joint Committee on Cancer (AJCC) TNM system—Stage 0-Stage IV. Ductal carcinoma in situ (DCIS), a non-invasive cancer which accounts for 20% of new breast cancer cases is Stage 0. Nearly all women diagnosed at this early stage of breast cancer can be cured. Infiltrating (invasive) ductal carcinoma (IDC), which accounts for 80% of invasive breast cancer and infiltrating (invasive) lobular carcinoma (ILC), which accounts for 5% of invasive breast cancers are more severe Stage I-IV cancers and can metastasize.
Breast Cancer Treatment
Breast-conserving surgery (lumpectomy) or mastectomy are the usual treatments for breast cancer. For stage I or II breast cancer, breast-conserving surgery is as effective as mastectomy. Patients can then undergo reconstructive surgery. Axillary lymph node sampling and removal or sentinel lymph node biopsy (SLNB) is performed to see if the cancer has spread to the lymph nodes.
Neoadjuvant chemotherapy can be given before surgery to shrink large cancers. Adjuvant chemotherapy after surgery reduces the risk of breast cancer recurrence. Chemotherapy can also be used as the main treatment for women whose cancer has spread outside the breast and underarm area. Chemotherapeutic agents used include anthracyclines (e.g. methotrexate, fluorouracil, doxorubicin, epirubicin), taxanes (e.g. paclitaxel, docetaxel, vinorelbine) and alkylating agents (e.g. cyclophosphamide).
Radiation therapy (usually external beam radiation but sometimes brachytherapy) is given once chemotherapy is complete.
Hormone therapy with selective estrogen receptor modulators (e.g. tamoxifen) can be given to women with estrogen receptor positive breast cancers. Taking tamoxifen after surgery for 5 years can reduce recurrence by about 50% in women with early breast cancer. Aromatase inhibitors such as exemestane, letrozole or anastrozole can also be used.
Women with HER2 positive cancers (about ⅓ of breast cancers) can be given biological response modifiers such as trastuzumab (Herceptin). Clinical trials have shown that adding trastuzumab to chemotherapy lowers the recurrence rate and death rate over chemotherapy alone after surgery in women with HER2 positive early breast cancers.
Breast Cancer Survival by Stage
Patients diagnosed with breast cancer between 1995 and 1998 had a 5 year relative survival rate of 100% for stage 0 and I, 92% for stage IIA, 81% for stage IIB, 67% for stage IIIA, 54% for stage IIIB and 20% for stage IV.
Colorectal Cancer
Colorectal cancer (CRC) is one of the leading causes of cancer-related morbidity and mortality, responsible for an estimated half a million deaths per year, mostly in Western, well developed countries. In these territories, CRC is the third most common malignancy (estimated number of new cases per annum in USA and EU is approximately 350,000 per year). Estimated healthcare costs related to treatment for colorectal cancer in the United States are more than $8 billion.
Colorectal Cancer Diagnosis
Today, the fecal occult blood test and colonoscopy, a highly invasive procedure, are the most frequently used screening and diagnostic methods for colorectal cancer. Other diagnostic tools include Flexible Sigmoidoscopy (allowing the observation of only about half of the colon) and Double Contrast Barium Enema (DCBE, to obtain X-ray images).
Colorectal Cancer Staging
CRC has four distinct stages: patients with stage I disease have a five-year survival rate of >90%, while those with metastatic stage IV disease have a <5% survival rate according to the US National Institutes of Health (NIH).
Colorectal Cancer Treatment
Once CRC has been diagnosed, the correct treatment needs to be selected. Surgery is usually the main treatment for rectal cancer, although radiation and chemotherapy will often be given before surgery. Possible side effects of surgery include bleeding from the surgery, deep vein thrombosis and damage to nearby organs during the operation.
Currently, 60 percent of colorectal cancer patients receive chemotherapy to treat their disease; however, this form of treatment only benefits a few percent of the population, while carrying with it high risks of toxicity, thus demonstrating a need to better define the patient selection criteria.
Colorectal cancer has a 30 to 40 percent recurrence rate within an average of 18 months after primary diagnosis. As with all cancers, the earlier it is detected the more likely it can be cured, especially as pathologists have recognised that the majority of CRC tumours develop in a series of well-defined stages from benign adenomas.
Colorectal Cancer Survival by Stage:
For stage I 93%, for stage IIA 85%, for stage IIB 72%, for stage IIIA 83%, for stage IIIB 64%, for stage IIIC 44% and for stage IV 8%.
Gastric Cancer
Gastric cancer is the second-leading cause of cancer-related deaths in the world, with about 700,000 deaths per year, mostly in less developed countries. In the USA, about 22,000 people are diagnosed with gastric cancer each year, with about 11,000 deaths. This figure is approximately ten times higher in Japan. Two thirds of people diagnosed with gastric cancer are older than 65.
Gastric Cancer Diagnosis
Early stage gastric cancer rarely causes symptoms so only about 10-20% of gastric cancers in the USA are found in the early stages, before they have spread to other areas of the body. Studies in the USA have not found mass screening for gastric cancer to be useful because the disease is not that common. Endoscopy followed by a biopsy is the main procedure used to diagnose gastric cancer. Other diagnostic methods include barium upper gastrointestinal radiographs, endoscopic ultrasound, CT scan, PET scan, MRI scan, chest x-ray, laparoscopy, complete blood count (CBC) test and fecal occult blood test.
Gastric Cancer Staging
Gastric cancer is staged using the American Joint Commission on Cancer (AJCC) TNM system—Stage 0-Stage IV. Patients with stage 0 disease have a 5-year survival rate of >90%, while there is usually no cure for patients with stage IV disease where the 5-year survival rate is only 7%. The overall 5-year relative survival rate of people with gastric cancer in the USA is about 23%. The 5-year survival rate for cancers of the proximal stomach is lower than for cancers in the distal stomach.
Gastric Cancer Treatment
Surgery is the only way to cure gastric cancer. There are three types of surgery used—endoscopic mucosal resection (only for early stage gastric cancer), subtotal gastrectomy or total gastrectomy. Gastric cancer often spreads to lymph nodes so these must also be removed. If the cancer has extended to the spleen, the spleen is also removed. Surgery for gastric cancer is difficult and complications can occur.
Chemotherapy may be given as the primary treatment for gastric cancer that has spread to distant organs. Chemotherapy together with external beam radiation therapy may delay cancer recurrence and extend the life span of people with less advanced gastric cancer, especially when the cancer could not be removed completely by surgery. Chemotherapeutic agents used include fluorouracil, doxorubicin, methotrexate, etoposide and cisplatin. More recently, imatinib mesylate (Gleevec) has been trialled in gastrointestinal stromal tumours (GIST), improving progression free survival.
Gastric Cancer Survival by Stage:
For stage 0 greater than 90%, for stage IA 80% for stage IB 60%, for stage II 34%, for stage IIIA 17%, for stage IIIB 12% and stage IV 7%.
Head and Neck Cancer
The term head and neck cancer refers to a group of biologically similar cancers originating from the upper aerodigestive tract, including the lip, oral cavity (mouth), nasal cavity, paranasal sinuses, pharynx, and larynx. Most head and neck cancers are squamous cell carcinomas, originating from the mucosal lining (epithelium) of these regions. Head and neck cancers often spread to the lymph nodes of the neck, and this is often the first manifestation of the disease at the time of diagnosis.
The number of new cases of head and neck cancers in the United States was 40,490 in 2006, accounting for about 3% of adult malignancies. 11,170 patients died of their disease in 2006. The worldwide incidence exceeds half a million cases annually. 85% of head and neck cancers are linked to tobacco use. In North America and Europe, the tumours usually arise from the oral cavity, oropharynx, or larynx, whereas nasopharyngeal cancer is more common in the Mediterranean countries and in the Far East. In Southeast China and Taiwan, head and neck cancer, specifically nasopharyngeal cancer is the most common cause of death in young men. African Americans are disproportionately affected by head and neck cancer, with younger ages of incidence, increased mortality, and more advanced disease at presentation.
Head and Neck Cancer Diagnosis
Head and neck cancer is diagnosed using a combination of tests which can include a physical examination, endoscopy, X-ray, computed tomography (CT) scan, magnetic resonance imaging (MRI) scan, PET scan and a biopsy. Early signs of head and neck cancer are often not detected and the majority of head and neck cancer patients present with advanced disease and often have secondary tumours.
Head and Neck Cancer Staging
Head and neck cancer is staged using the American Joint Committee on Cancer (AJCC) TNM system—stage I-IV. The 5-year survival for all stages of head and neck cancer is 35-50%, due, in part, to late presentation. Stage I and II survival rates range from 40-95% and stage III and IV survival rates range from 0-50%. It is predicted that at least one third of patients with head and neck cancer will ultimately die as a result of their disease. The 5-year mortality rate has not altered significantly in the last few decades, despite advances in treatment modalities.
Head and Neck Cancer Treatment
Surgery and radiation therapy are the primary modalities of therapy, often in combination. Chemotherapy can be used as an induction therapy or as an adjuvant to radiation therapy, with or without surgery.
Kidney Cancer
Kidney cancer accounts for about 1.9% of cancer cases globally and 1.5% of deaths. Global incidence of kidney cancer is around 208,000 cases, with over 100,000 deaths. The incidence of kidney cancer is much higher in developed countries, being the sixth most common form of cancer in Western Europe. Around 38,900 new cases of kidney cancer are diagnosed in the USA each year, with around 12,800 deaths. It is very uncommon under age 45, and its incidence is highest between the ages of 55 and 84. The rate of people developing kidney cancer has been increasing at about 1.5% per year but the death rate has not been increasing. Renal cell carcinoma accounts for more than 90% of malignant kidney tumours. It has been estimated that approximately US$1.9 billion is spent in the USA each year on treating kidney cancer.
Kidney Cancer Diagnosis
Many renal cell cancers are found at a late stage; they can become quite large without causing any pain or discomfort and there are no simple tests that can detect renal cell cancer early. About 25% of patients with renal cell carcinoma will already have metastatic spread of their cancer when they are diagnosed.
Renal cell cancer can often be diagnosed without the need for a biopsy using a CT scan, MRI, ultrasound, positron emission tomography (PET) scan, intravenous pyelogram (IVP) and/or angiography. Fine needle aspiration biopsy may however be valuable when imaging results are not conclusive enough to warrant removing a kidney.
Kidney Cancer Staging
Renal cell cancers are usually graded on a scale of 1-4. Renal cell cancer is also staged using the American Joint Committee on Cancer (AJCC) TNM system—stage I-IV. The University of California Los Angeles Integrated Staging System can also be used, which divides patients without any tumour spread into three groups—low risk, intermediate risk and high risk. The 5-year cancer-specific survival for the low-risk group is 91%, for the intermediate-risk group is 80%, and for the high-risk group is 55%. Patients with tumour spread are also divided into three groups—low, intermediate and high risk. The 5-year cancer-specific survival for the low-risk group is 32%, for the intermediate-risk group 20% and for the high-risk group 0%.
Kidney Cancer Treatment
Surgery by radical nephrectomy (and sometimes regional lymphadenectomy), partial nephrectomy or laparoscopic nephrectomy is the main treatment for renal cell carcinoma. Renal cell carcinomas are not very sensitive to radiation so using radiation therapy before or after removing the cancer is not routinely recommended because studies have shown no improvement in survival rates.
Renal cell cancers are very resistant to present forms of chemotherapy. Some drugs, such as vinblastine, floxuridine, and 5-fluorouracil (5-FU) are mildly effective. A combination of 5-FU and gemcitabine has benefited some patients. A 5-FU-like drug, capecitabine, may also have some benefit.
Cytokines (interleukin-2 (IL-2) and interferon-alpha) have become one of the standard treatments for metastatic renal cell carcinoma. These cause the cancers to shrink to less than half their original size in about 10% to 20% of patients. Patients who respond to IL-2 tend to have lasting responses. Recent research with a combination of IL-2, interferon, and chemotherapy (using 5-fluorouracil) is also promising and may offer a better chance of partial or complete remission. Cytokine therapy does have severe side affects however.
Sorafenib (Nexavar), Sunitinib (Sutent) and Bevacizumab (Avastin) are other drugs which may also be effective against renal cell cancer.
Kidney Cancer Survival by Stage
T stage cancer5/10-year cancer-specific survivalT195%/91%T280%/70%T3a66%/53%T3b52%/43%T3c43%/42%Lung Cancer
Lung cancer is the most common form of cancer worldwide (accounting for about 12% of cancer cases) and the main cause of death from cancer (accounting for about 18% of deaths).
Global incidence of lung cancer is over 1,300,000 per year, with the number of deaths over 1,100,000. In the USA, there are about 170,000 new cases per year (about 13% of all cancers), with about 160,000 deaths (about 28% of cancer deaths). Lung cancer is much more prevalent among men than women. Nearly 70% of people diagnosed with lung cancer are older than 65; fewer than 3% of all cases are found in people under the age of 45. Around 15% of all lung cancers are small cell type (SCLC), which tend to spread widely through the body, while the remaining 85% are non-small cell (NSCLC). It has been estimated that approximately US$9.6 billion is spent in the USA each year on treating lung cancer.
Lung Cancer Diagnosis
Lung cancer is a life-threatening disease because it often metastasises even before it can be detected on a chest x-ray. Usually symptoms of lung cancer do not appear until the disease is in an advanced stage. So far, there is no screening test that has been shown to improve a person's chance for a cure. Imaging tests such as a chest x-ray, CT scan, MRI scan or PET scan may be used to detect lung cancer. Tests to confirm the diagnosis are then performed and include sputum cytology, needle biopsy, bronchoscopy, endobronchial ultrasound and complete blood count (CBC).
Lung Cancer Staging
Nearly 60% of people diagnosed with lung cancer die within one year of diagnosis; 75% die within 2 years. The 5-year survival rate for people diagnosed with NSCLC is about 15%; for SCLC the 5-year survival rate is about 6%. NSCLC is staged using the American Joint Committee on Cancer (AJCC) TNM system—Stage 0-Stage IV. The 5-year survival rates by stage are as follows: stage I: 47%; stage II; 26%; stage III: 8% and stage IV: 2%. SCLC has a 2-stage system—limited stage and extensive stage. About two thirds of SCLC patients have extensive disease at diagnosis. If SCLC is found very early and is localised to the lung alone, the 5-year survival rate is around 21%, but only 6% of patients fall into this category. Where the cancer has spread, the 5-year survival is around 11%. For patients with extensive disease, the 5-year survival is just 2%.
Lung Cancer Treatment
Surgery is the only reliable method to cure NSCLC. Types of surgery include lobectomy, pneumonectomy, segmentectomy and video-assisted thoracic surgery (for small tumours).
External beam radiation therapy is sometimes used as the primary treatment, especially if the patient's health is too poor to undergo surgery. Radiation therapy can also be used after surgery. Chemotherapy may be given as the primary treatment or as an adjuvant to surgery. Targeted therapy using epidermal growth factor receptor (EGFR) antagonists such as gefitinib or erlotinib can also be given after other treatments have failed. Antiangiogenic drugs, such as bevacizumab, have been found to prolong survival of patients with advanced lung cancer. Photodynamic therapy is also being researched as a treatment for lung cancer.
The main treatment for SCLC is chemotherapy, either alone or in combination with external beam radiation therapy and very rarely, surgery.
Chemotherapeutic agents used for NSCLC and SCLC include cisplatin, carboplatin, mitomycin C, ifosfamide, vinblastine, gemcitabine, etoposide, vinorelbine, paclitaxel, docetaxel and irinotecan.
Osteosarcoma
Osteosarcoma is the most common bone cancer in children, adolescents and young adults (accounting for approximately 5% of childhood tumours) but it is still a rare disease with an annual incidence of 2-3 per million in the general population. There are about 900 new cases of osteosarcoma diagnosed in the United States each year (about 400 of which occur in children and adolescents younger than 20 years old), with approximately 300 deaths each year. Osteosarcoma is a primary malignant tumour of the appendicular skeleton that is characterized by the direct formation of bone or osteoid tissue by the tumour cells. In children and adolescents, more than 50% of these tumours arise from the bones around the knee. Many people with osteosarcoma can be cured but not all and the price of cure even with the most modern treatments is high.
Osteosarcoma Diagnosis
Diagnostic methods for osteosarcoma include an X-ray, bone scan, CT scan, PET scan and MRI of the affected area. A CT scan of the chest is also conducted to see if the cancer has spread to the lungs. Blood tests can be used to detect serum levels of alkaline phosphatase and/or LDH, which are increased in a considerable number of osteosarcoma patients, although serum levels do not correlate reliably with disease extent. The diagnosis of osteosarcoma must be verified histologically with a core needle biopsy or open biopsy. Micrometastatic disease is present at diagnosis in 80-90% of patients but undetectable with any of present tests.
Osteosarcoma Staging
There are two staging systems for osteosarcoma: the Enneking system where low-grade tumours are stage I, high-grade tumours are stage II, and metastatic tumours (regardless of grade) are stage III and the American Joint Commission on Cancer (AJCC) system which stages osteosarcoma from IA to IVB.
There are essentially 2 categories of patients: those who present without clinically detectable metastatic disease (localized osteosarcoma) and the 15-20% of patients who present with clinically detectable metastatic disease (metastatic osteosarcoma). 85% to 90% of metastatic disease is in the lungs.
Osteosarcoma has one of the lowest survival rates for pediatric cancer. The overall 5-year survival rate for patients with non-metastatic osteosarcoma is over 70%. The 5-year survival rate for patients whose cancers have already metastasised at the time of their diagnosis is about 30%.
Osteosarcoma Treatment
Once osteosarcoma has been diagnosed, the correct treatment needs to be selected. Successful treatment generally requires the combination of effective systemic chemotherapy and complete resection (amputation, limb preservation, or rotationplasty) of all clinically detectable disease (including resection of all overt metastatic disease). Protective weight bearing is recommended for patients with tumours of weight-bearing bones to prevent pathological fractures that could preclude limb-preserving surgery.
At least 80% of patients with localized osteosarcoma treated with surgery alone will develop metastatic disease. Randomized clinical trials have established that adjuvant chemotherapy is effective in preventing relapse or recurrence in patients with localized resectable primary tumours. The chemotherapeutic agents used include high-dose methotrexate, doxorubicin, cisplatin, high-dose ifosfamide, etoposide, carboplatin, cyclophosphamide, actinomycin D and bleomycin. Bone-seeking radioactive chemicals are sometimes used to treat osteosarcoma. Samarium-153 may be given in addition to external beam radiation therapy.
There is no difference in overall survival (OS) between patients initially treated by amputation and those treated with a limb-sparing procedure. In general, more than 80% of patients with extremity osteosarcoma can be treated by a limb-sparing operation and do not require amputation. Complications of limb-salvage surgery include infection and grafts or rods that become loose or broken. Limb-salvage surgery patients may need more surgery during the following 5 years, and some may eventually need an amputation. Limb length inequality is also a major potential problem for young children. Treatment options include extensible prostheses, amputation, and rotationplasty for these children.
Most recurrences of osteosarcoma develop within 2 to 3 years after treatment completion. Fewer than 30% of patients with localized resectable primary tumours treated with surgery alone can be expected to survive free of relapse. Recurrence of osteosarcoma is most often in the lung.
The ability to achieve a complete resection of recurrent disease is the most important prognostic factor at first relapse, with a 5-year survival rate of 20% to 45% following complete resection of metastatic pulmonary tumours and 20% following complete resection of metastases at other sites. Repeated resections of pulmonary recurrences can lead to extended disease control and possibly cure for some patients. Survival for patients with unresectable metastatic disease is less than 5%. Resection of metastatic disease followed by observation alone results in low overall and disease-free survival.
Pancreatic Cancer
Pancreatic cancer is a very difficult cancer to detect and the prognosis for patients is usually very poor. The number of new cases and deaths per year is almost equal. Global incidence of pancreatic cancer is approximately 230,000 cases (about 2% of all cancer cases), with about 225,000 deaths (3.4% of cancer deaths) per year. It is much more prevalent in the developed world. In the USA, there are about 34,000 new cases per year, with about 32,000 deaths. It has been estimated that approximately US$1.5 billion is spent in the USA each year on treating pancreatic cancer.
Pancreatic Cancer Diagnosis
Pancreatic cancer is very difficult to detect and very few pancreatic cancers are found early. Patients usually have no symptoms until the cancer has spread to other organs. There are currently no blood tests or easily available screening tests that can accurately detect early cancers of the pancreas. An endoscopic ultrasound followed by a biopsy is the best way to diagnose pancreatic cancer. Other detection methods include CT, CT-guided needle biopsy, PET, ultrasonography and MRI. Blood levels of CA 19-9 and carcinoembryonic antigen (CEA) may be elevated but by the time blood levels are high enough to be detected, the cancer is no longer in its early stages.
Pancreatic Cancer Staging
Pancreatic cancer has four stages, stage I to stage IV according to the American Joint Committee on Cancer (AJCC) TNM system. Pancreatic cancer is also divided into resectable, locally advanced (unresectable) and metastatic cancer. For patients with advanced cancers, the overall survival rate is <1% at 5 years with most patients dying within 1 year.
Pancreatic Cancer Treatment
Surgery is the only method of curing pancreatic cancer. About 10% of pancreatic cancers are contained entirely within the pancreas at the time of diagnosis and attempts to remove the entire cancer by surgery may be successful in some of these patients. The 5-year survival for those undergoing surgery with the intent of completely removing the cancer is about 20%. Potentially curative surgery, usually by pancreaticoduodenectomy (Whipple procedure), is used when it may be possible to remove all of the cancer. Palliative surgery may be performed if the tumour is too widespread to be completely removed. Removing only part of the cancer does not allow patients to live longer. Pancreatic cancer surgery is difficult to perform with a high likelihood of complications.
External beam radiation therapy combined with chemotherapy can be given before or after surgery and can also be given to patients whose tumours are too widespread to be removed by surgery. The main chemotherapeutic agents which are used are gemcitabine and 5-fluorouracil. Targeted therapy using drugs such as erlotinib and cetuximab may be of benefit to patients with advanced pancreatic cancer.
Prostate Cancer
Prostate cancer is the third most common cancer in the world amongst men and it accounts for 5.4% of all cancer cases globally and 3.3% of cancer-related deaths. Global incidence of prostate cancer is around 680,000 cases, with about 221,000 deaths. In the USA, prostate cancer is the most common cancer, other than skin cancers, in American men. About 234,460 new cases of prostate cancer are diagnosed in the USA each year. About 1 man in 6 will be diagnosed with prostate cancer during his lifetime, but only 1 in 34 will die of it. A little over 1.8 million men in the USA are survivors of prostate cancer. The risk of developing prostate cancer rises significantly with age and 60% of cases occur in men over the age of 70. Prostate cancer is the second leading cause of cancer death in American men. Around 27,350 men in the USA die of prostate cancer each year. Prostate cancer accounts for about 10% of cancer-related deaths in men. Modern methods of detection and treatment mean that prostate cancers are now found earlier and treated more effectively. This has led to a yearly drop in death rates of about 3.5% in-recent years. Prostate cancer is most common in North America and northwestern Europe. It is less common in Asia, Africa, Central America, and South America. It has been estimated that approximately US$8.0 billion is spent in the USA each year on treating prostate cancer.
Prostate Cancer Diagnosis
Prostate cancer can often be found early by testing the amount of prostate-specific antigen (PSA) in the blood. A digital rectal exam (DRE) can also be performed. However, there are potential problems with the current screening methods. Neither the PSA test nor the DRE is 100% accurate. A core needle biopsy is the main method used to diagnose prostate cancer. A transrectal ultrasound (TRUS) may be used during a prostate biopsy.
Prostate Cancer Staging
Prostate cancers are graded according to the Gleason system, graded from 1-5, which results in the Gleason score, from 1-10. Prostate cancer is staged using the American Joint Committee on Cancer (AJCC) TNM system and combined with the Gleason score to give stages from I-IV.
Ninety one percent of all prostate cancers are found in the local and regional stages; the 5-year relative survival rate for these men is nearly 100%. The 5-year relative survival rate for men whose prostate cancers have already spread to distant parts of the body at the time of diagnosis is about 34%.
Prostate Cancer Treatment
Because prostate cancer often grows very slowly, some men never have treatment and expectant management is recommended. If treatment is required and the cancer is not thought to have spread outside of the gland, a radical prostatectomy can be performed. Transurethral resection of the prostate (TURP) can be performed to relieve symptoms but not to cure prostate cancer.
External beam radiation therapy (three-dimensional conformal radiation therapy (3DCRT), intensity modulated radiation therapy (IMRT) or conformal proton beam radiation therapy) or brachytherapy can also be used as treatment.
Cryosurgery is sometimes used to treat localized prostate cancer but as not much is known about the long-term effectiveness of cryosurgery, it is not routinely used as a first treatment for prostate cancer. It can be used for recurrent cancer after other treatments.
Androgen deprivation therapy (ADT) (orchiectomy or luteinizing hormone-releasing hormone (LHRH) analogs or antagonists) can be used to shrink prostate cancers or make them grow more slowly.
Chemotherapy is sometimes used if prostate cancer has spread outside of the prostate gland and is hormone therapy resistant. Chemotherapeutic agents include docetaxel, prednisone, doxorubicin, etoposide, vinblastine, paclitaxel, carboplatin, estramustine, vinorelbine. Like hormone therapy, chemotherapy is unlikely to result in a cure.
Skin Cancer
Skin cancer is the most common type of cancer, accounting for at least half of all cancers. Skin cancers that develop from melanocytes are called melanomas. Melanoma accounts for about 4% of skin cancer cases but causes a large majority of skin cancer deaths. In the USA, about 62,000 new melanomas are diagnosed each year, with around 8,000 deaths.
A much more common type of skin cancer is keratinocyte cancer which includes basal cell carcinoma and squamous cell carcinoma. Basal cell carcinomas account for about 80% of non-melanoma skin cancers and squamous cell carcinomas account for about 20%. More than 1 million basal and squamous cell skin cancers are diagnosed each year. Death from these cancers is uncommon; about 2,000 people die every year from non-melanoma skin cancers. The death rate has dropped about 30% in the past 30 years.
Skin Cancer Diagnosis
A skin biopsy is used to diagnose skin cancer. Types of skin biopsy include excisional biopsy, incisional biopsy, shave biopsy and punch biopsy. Metastatic skin cancer can be diagnosed using a number of methods including fine needle aspiration biopsy, surgical lymph node biopsy and sentinel lymph node mapping and biopsy. Imaging tests such as a chest x-ray, computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) and nuclear bone scans can also be used.
Skin Cancer Staging
Melanoma is staged using the American Joint Committee on Cancer (AJCC) TNM system—Stage 0-Stage IV. The thickness of the melanoma is measured using the Breslow measurement. Basal cell cancer rarely spreads to other organs and so it is seldomly staged. Staging using the AJCC TNM system is sometimes done for squamous cell cancers.
Skin Cancer Treatment
Most basal cell and squamous cell carcinomas can often be completely cured by fairly minor surgery including simple excision, curettage and electrodesiccation or Mohs surgery (microscopically-controlled surgery). Cryotherapy, photodynamic therapy or topical chemotherapy using 5-fluorouracil can also be used as treatment options for these skin cancers. For certain squamous cell cancers with a high risk of spreading, surgery may sometimes be followed by radiation or chemotherapy. Chemotherapeutic drugs which can be used include cisplatin, doxorubicin, fluorouracil (5-FU), and mitomycin. Radiation may be used as the primary treatment in cases where the tumour is very large or is located on an area of the skin that makes surgery difficult.
Thin melanomas can be completely cured by excision. If the melanoma is on a finger or toe, treatment may involve amputation of the digit. If the melanoma has spread to the lymph nodes, lymph node dissection may be required.
No current treatment is usually able to cure stage IV melanoma. Although chemotherapy is usually not as effective in melanoma as in some other types of cancer, it may relieve symptoms or extend survival of some patients with stage N melanoma. Chemotherapy drugs often used to treat melanoma include dacarbazine, carmustine, cisplatin, vinblastine and temozolomide. Recent studies have found that biochemotherapy, combining several chemotherapy drugs with 1 or more immunotherapy drugs may be more effective than a single chemotherapy drug alone. Immunotherapy drugs include interferon-alpha and/or interleukin-2. Radiation therapy may be used to treat recurrent melanoma and is used as palliation of metastases to the bone and brain.
Melanoma Survival By Stage
Stage5-year relative survival rate10-year relative survival rate097%—I90-95%80%IIA78%64%IIB63-67%51-54%IIC45%32%IIIA63-70%57-63%IIIB46-53%38%IIIC28%15-25%IV18%14%Thyroid Cancer
The two most common types of thyroid cancer are papillary carcinoma which accounts for 80% of thyroid cancers and follicular carcinoma which accounts for 10% of thyroid cancers. These are differentiated thyroid cancers which develop from the thyroid follicular cells. Papillary carcinomas grow very slowly; they often spread to lymph nodes in the neck but most of the time, this can be successfully treated and is rarely fatal. Follicular carcinomas usually don't spread to the lymph nodes but can spread to other parts of the body, such as the lungs or bones. The prognosis is not as good as for papillary carcinoma but it still very good in most cases. Other types of thyroid cancer include Hurthle cell carcinoma, medullary thyroid carcinoma and anaplastic carcinoma all of which are less common but harder to treat and have a worse prognosis than papillary carcinoma and follicular carcinoma.
There are around 37,000 new cases of thyroid cancer each year in the United States with about 1,600 deaths. The 5-year survival rate is very good at about 97%. Thyroid cancer mainly affects younger people with around 66% of cases found in people between the ages of 20 and 55.
Thyroid Cancer Diagnosis
Thyroid cancer is diagnosed by fine needle aspiration biopsy. Imaging tests such as a chest x-ray to see if the cancer has spread to the lungs, an ultrasound, a computed tomography (CT) scan, a magnetic resonance imaging (MRI) scan or a radioiodine scan may also be performed. Blood levels of thyroid-stimulating hormone (TSH) may be checked to determine the activity of the thyroid gland. For medullary thyroid carcinoma, levels of calcitonic and carcinoembryonic antigen (CEA) are often high so this can be measured to aid in diagnosis.
Thyroid Cancer Staging
Thyroid cancer has four stages, stage I to stage IV according to the American Joint Committee on Cancer (AJCC) TNM system. Unlike most other cancers, thyroid cancers are grouped into stages in a way that takes into account both the subtype of cancer and the patient's age. For papillary or follicular thyroid carcinoma, all people under the age of 45 are either stage I or stage II. Patients 45 years and older can be stage I-IV. Stage grouping for medullary thyroid carcinoma in people of any age is the same as for papillary or follicular carcinoma in people older than age 45. All anaplastic thyroid cancers are considered stage N, reflecting the poor prognosis of this type of cancer.
Thyroid Cancer Treatment
Surgery is the main treatment for thyroid cancer and is used in almost every case, except some anaplastic thyroid cancers. Lobectomy can be used for small differentiated thyroid cancers but thyroidectomy is the most common surgery. Lymph node removal is performed when the cancer has spread outside the thyroid gland. Patients who have undergone total thyroidectomy will need to take daily thyroid hormone replacement pills.
Radioactive iodine can be used to destroy any thyroid tissue not removed by surgery or to treat thyroid cancer that has spread to lymph nodes and other parts of the body. Radioactive iodine therapy is not used to treat anaplastic and medullary thyroid carcinomas because these types of cancer do not take up iodine. External beam radiation therapy can be used in these cases.
Thyroid Cancer Survival By Stage
Relative 5-year survival rates by stage for papillary thyroid cancer are: Stage I: 100%; Stage II: 100%; Stage III: 96%; Stage IV: 45%; for follicular thyroid cancer: Stage I: 100%; Stage II: 100%; Stage III: 79%; Stage IV: 47%; for medullary thyroid cancer: Stage I: 100%; Stage II: 97%; Stage III: 78%; Stage IV: 24% and for anaplastic thyroid cancer all are stage N and the relative 5-year survival rate is around 9%.
Uterine Cancer
Endometrial cancer is the most common form of uterine cancer. It refers to several types of malignancy which arise from the endometrium, or lining of the uterus. Other types of uterine cancer, such as uterine sarcoma, develop from other tissues of the uterus. Uterine sarcoma is much less common than endometrial cancer, accounting for about 4% of cancers of the uterus. Uterine cancer is the most common gynaecologic cancer in the United States, with over 40,000 women diagnosed each year. Uterine cancer is the third most common cause of gynaecologic cancer death (behind ovarian and cervical cancer), with over 7,000 deaths per year in the United States.
Most cases of uterine cancer are found in women aged 55 and over. The average chance of a woman being diagnosed with uterine cancer during her lifetime is about one in 41.
Uterine Cancer Diagnosis
Most uterine cancers are detected at an early stage. About 90% of patients diagnosed with uterine cancer have abnormal vaginal bleeding. An endometrial biopsy is the most commonly performed test for uterine cancer, often with a hysteroscopy. Sometimes, a dilation and curettage will be performed. Imaging tests such as a transvaginal ultrasound and blood tests such as a complete blood count (CBC) and a CA 125 blood test can also be performed.
Uterine Cancer Staging
Uterine cancer is graded based on how much it looks like normal endometrium. A cancer is called grade 1 if 95% or more of the cancer forms glands similar to those of normal endometrial tissue. Grade 2 tumours have between 50% and 94% gland formations. Cancers with less than half of the tissue forming glands are given a grade of 3.
The main system used to stage uterine cancer is the FIGO (International Federation of Gynecology and Obstetrics) system, which is a surgical staging system. The FIGO system classifies the cancer in stages I through IV. The American Joint Committee on Cancer (AJCC) TNM system can also be used and the stages exactly match those in FIGO.
The overall 5-year relative survival rate is about 88%. When the cancer is found at an early stage, the 5-year survival rate is over 95%.
Uterine Cancer Treatment
A total abdominal hysterectomy with bilateral salpingo-oophorectomy is the most common therapeutic approach for uterine cancer. A radical hysterectomy is sometimes performed when the cancer has spread to the cervix. Lymph node sampling can be done at the same time as the hysterectomy. After hysterectomy, brachytherapy or external beam radiation therapy can be given. Chemotherapeutic drugs that can be used to treat endometrial cancer include doxorubicin (Adriamycin), cisplatin, carboplatin, and paclitaxel (Taxol). Ifosfamide is often used to treat carcinosarcoma.
Uterine Cancer Survival By Stage
Relative 5-year survival rates by stage for endometrial adenocarcinoma are: Stage IA: 99%; Stage IB: 99%; Stage IC: 92%; Stage II: 80%; Stage III: 60% and Stage IV: 30%. Relative 5-year survival rates for uterine carcinosarcoma are: Stage I: 70%; Stage II: 45%; Stage III: 30% and Stage IV: 15%.
Therapeutic Challenges
The major challenges in treatment of the above mentioned cancers are to improve early detection rates, to find new non-invasive markers that can be used to follow disease progression and identify relapse, and to find improved and less toxic therapies, especially for more advanced disease where 5 year survival is still poor. There is a great need to identify targets which are more specific to the cancer cells, e.g. ones which are expressed on the surface of the tumour cells so that they can be attacked by promising new approaches like immunotherapeutics and targeted toxins.